Surgery of Insular Diffuse Gliomas-Part 1: Transcortical Awake Resection Is Safe and Independently Improves Overall Survival

Johan Pallud; Marc Zanello; Alessandro Moiraghi; Sophie Peeters; Bénédicte Trancart; Myriam Edjlali; Catherine Oppenheim; Pascale Varlet; Fabrice Chrétien; Frédéric Dhermain; Alexandre Roux; Edouard Dezamis

doi:10.1093/neuros/nyab254

Surgery of Insular Diffuse Gliomas-Part 1: Transcortical Awake Resection Is Safe and Independently Improves Overall Survival

Neurosurgery. 2021 Sep 15;89(4):565-578. doi: 10.1093/neuros/nyab254.

Authors

Johan Pallud^{1

2}, Marc Zanello^{1

2}, Alessandro Moiraghi^{1

2}, Sophie Peeters³, Bénédicte Trancart^{1

2}, Myriam Edjlali^{2

4}, Catherine Oppenheim^{2

4}, Pascale Varlet^{2

4

5}, Fabrice Chrétien^{2

5}, Frédéric Dhermain⁶, Alexandre Roux^{1

2

4}, Edouard Dezamis^{1

2

4}

Affiliations

¹ Department of Neurosurgery, GHU Paris-Sainte-Anne Hospital, Paris, France.
² Université de Paris, Sorbonne Paris Cité, Paris, France.
³ Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA.
⁴ Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.
⁵ Department of Neuropathology, GHU Paris-Sainte-Anne Hospital, Paris, France.
⁶ Department of Radiotherapy, Gustave Roussy University Hospital, Villejuif, France.

PMID: 34383938
DOI: 10.1093/neuros/nyab254

Abstract

Background: Insular diffuse glioma resection is at risk of vascular injury and of postoperative new neurocognitive deficits.

Objective: To assess safety and efficacy of surgical management of insular diffuse gliomas.

Methods: Observational, retrospective, single-institution cohort analysis (2005-2019) of 149 adult patients surgically treated for an insular diffuse glioma: transcortical awake resection with intraoperative functional mapping (awake resection subgroup, n = 61), transcortical asleep resection without functional mapping (asleep resection subgroup, n = 50), and stereotactic biopsy (biopsy subgroup, n = 38). All cases were histopathologically assessed according to the 2016 World Health Organization classification and cIMPACT-NOW update 3.

Results: Following awake resection, 3/61 patients had permanent motor deficit, seizure control rates improved (89% vs 69% preoperatively, P = .034), and neurocognitive performance improved from 5% to 24% in tested domains, despite adjuvant oncological treatments. Resection rates were higher in the awake resection subgroup (median 94%) than in the asleep resection subgroup (median 46%; P < .001). There was more gross total resection (25% vs 12%) and less partial resection (34% vs 80%) in the awake resection subgroup than in the asleep resection subgroup (P < .001). Karnofsky Performance Status score <70 (adjusted hazard ratio [aHR] 2.74, P = .031), awake resection (aHR 0.21, P = .031), isocitrate dehydrogenase (IDH)-mutant grade 2 astrocytoma (aHR 5.17, P = .003), IDH-mutant grade 3 astrocytoma (aHR 6.11, P < .001), IDH-mutant grade 4 astrocytoma (aHR 13.36, P = .008), and IDH-wild-type glioblastoma (aHR 21.84, P < .001) were independent predictors of overall survival.

Conclusion: Awake surgery preserving the brain connectivity is safe, allows larger resections for insular diffuse gliomas than asleep resection, and positively impacts overall survival.

Keywords: Awake surgery; Diffuse glioma; Insula; Overall survival; Resection; Survival.

Publication types

Observational Study

MeSH terms

Adult
Brain Neoplasms* / surgery
Glioma* / surgery
Humans
Retrospective Studies
Treatment Outcome
Wakefulness